Chest pain is a common yet easily overlooked symptom. During the cold winter months, chest pain is becoming one of the most common causes of emergency room visits. The diseases of chest pain are complex and diverse, among which coronary heart disease is one of the most common and dangerous causes of chest pain.
The heart beats every minute of every day, acting as a pump, constantly recycling and pumping blood. The main component of the heart is the myocardium, and the blood supply to the myocardium comes from the left and right coronary arteries, which, if atherosclerosis occurs in these two arteries and their branches, will cause narrowing of the coronary artery lumen. Atherosclerosis often has no obvious symptoms in the early stage, but only in the middle and late stages or even when the coronary arteries are completely blocked, resulting in insufficient blood supply to the myocardium or myocardial necrosis, will obvious symptoms appear.
If the coronary artery is completely blocked for a long time, it will cause myocardial necrosis, which will lead to acute myocardial infarction, and the most important symptom of acute heart attack is chest pain. Compared with angina, the pain caused by myocardial infarction is more persistent and intense, sometimes for several days, and cannot be relieved by rest or nitroglycerin. This includes arrhythmias, angina, acute myocardial infarction, heart failure and even sudden death. Patients with coronary artery disease should not neglect the necessary examination and treatment because angina is sporadic or not serious.
Typical angina is not really severe pain, but manifests itself as a paroxysmal anterior chest squeezing and tightening sensation, pressure and suffocation or stuffiness. This pain is mainly located in the middle of the chest and also radiates to the left anterior chest and left upper extremity. Patients often have episodes when they are engaged in physical labor or emotional stress. Some patients have episodes not in the mid chest or precordial region, but instead present with toothache, shoulder and back pain, neck stiffness, or epigastric pain.
Chest pain can also be seen in non-coronary heart diseases such as.
(1) Chest discomfort or chest pain due to emotional or mental factors.
Also known as cardiac neurosis, it is mostly seen in young and middle-aged women or menopausal women. In fact, premenopausal women without risk factors (such as family history, hypertension, dyslipidemia and diabetes) rarely develop coronary heart disease. Such patients may have ST-segment shift, or T-wave changes, and should do Propranolol (Propranolol) test, most of the electrocardiogram becomes normal after taking Propranolol.
For patients with ST segment or T wave changes should also perform exercise stress test, or even echocardiography, radioisotope examination, still can not be sure for coronary artery angiography. Attention should be paid to the patient’s age and gender, psychosocial factors, and the presence of risk factors for coronary heart disease.
(2) Chest discomfort caused by non-coronary heart disease
(1) Premature beats
Premature beats may be accompanied by chest discomfort or even pain, mostly during inactivity and disappearing or not felt after activity. It should be determined whether the premature beats are benign or accompanied by heart disease, and an ambulatory electrocardiogram, cardiac exercise stress test or echocardiogram should be performed if necessary.
Acute pericarditis
Especially in the early stages of pericarditis, there may be pain in the precordial region and retrosternal area, often associated with deep breathing, coughing or position changes, and sometimes painful swallowing. Early pericardial rubbing sounds may be present, and the pericardial rubbing sounds and chest pain often disappear after the appearance of a large amount of effusion. ST-segment and T-wave changes in the ECG are often located in all leads except aVR, and ST-segment elevation is bowed downward, which may be accompanied by signs and symptoms of pericardial compression, as well as systemic symptoms, and the diagnosis can be confirmed by echocardiography.
(iii) Myocarditis and dilated cardiomyopathy
Symptoms such as chest tightness and dyspnea may be present. Changes in QRS integrated wave, ST segment and T wave can be found on ECG. Attention should be paid to history taking, careful physical examination, observation of any evolution of ECG, series of myocardial enzymology and echocardiography and other examinations.
④Right ventricular hypertension, pulmonary hypertension
Angina pectoris can be caused by right ventricular ischemia, commonly seen in mitral stenosis with pulmonary hypertension, pulmonary stenosis, etc.
⑤ Cardiac hyperdynamic syndrome and mitral valve prolapse
Patients often complain of panic, precordial discomfort, fatigue, dyspnea, anxiety and excessive sweating, etc. Beta blockers are effective. The electrocardiogram can be confused with coronary artery disease, and the exercise test can be false-positive. Mitral valve prolapse can also be accompanied by sympathetic excitation and hyperdynamic state, often with clinical manifestations of neurasthenia, and cardiac ultrasound can confirm the diagnosis.
(6) Acute aortic coarctation
Aortic coarctation can present with severe chest pain and can also involve the coronary arteries, even with myocardial infarction. The general site of chest pain is high, often tearing-like, peaking at the beginning, and may radiate widely to the back, abdominal lumbar region and legs. There may be abnormal pulsations in the chest, abnormal murmurs due to entrapment may be heard, mismatch of blood pressure in both upper or upper and lower extremities, diminished pulse on one side, and paralysis or hemiparesis in the lower extremities.
Involvement of the aortic root may result in aortic valve closure insufficiency. X-ray chest film, echocardiography or magnetic resonance imaging should be performed promptly, and aortogram should be performed if surgery is considered.
(7) Acute pulmonary embolism
Acute massive pulmonary embolism may cause chest pain, dyspnea, syncope, shock and other manifestations, and the patient may be accompanied by cold sweat, cyanosis or sense of near death. However, the patient’s physical examination, electrocardiogram and X-ray chest film often show the manifestation of acute pulmonary hypertension or acute right heart insufficiency, such as pulmonary P wave, right bundle branch block or more specific SIQIITIII on electrocardiogram; the upper vena cava shadow is widened, the right lower pulmonary artery is widened or the pulmonary artery segment is prominent, and the texture of the external and external lung fields is reduced on X-ray chest film. If necessary, pulmonary artery plus coronary angiography should be performed.
Chest pain can also be seen in non-cardiac diseases such as.
(1) Chest and lung diseases
(1) Chest trauma: tenderness, pain associated with coughing, deep breathing, posture or certain activities.
②costochondritis and intercostal neuralgia: stabbing or burning pain, which can be related to activity, with well-defined pressure points, sometimes accompanied by neurological manifestations, no changes in ECG, and no high cardiac enzymes. Other chest wall pain can be caused by intercostal muscle strain, viral infection, and chest pain characterized by sharp pain with tenderness, which can be aggravated by coughing and deep breathing.
(iii) Herpes zoster of the chest: it can be confused with myocardial ischemic pain before the appearance of herpes. The affected area shows hypersensitivity of the skin with tenderness, and there may be headache, fever and general malaise.
④Pneumonia: the electrocardiogram may show manifestations similar to myocardial infarction or myocardial ischemia, but not consistent with the evolution of myocardial infarction or myocardial ischemia, with symptoms such as fever, cough or sputum, and series of myocardial enzymology and X-ray chest radiographs can be differentiated.
⑤ Spontaneous pneumothorax: sudden chest pain and dyspnea, chest pain on the side of the occurrence of pneumothorax, drum sound on chest percussion, X-ray chest film can confirm the diagnosis.
(6) Mediastinal emphysema: chest pain and mediastinal twang sound are typical manifestations, subcutaneous emphysema may appear in the upper part of the neck or chest, and X-ray chest film can confirm the diagnosis.
(vii) Thoracic outlet syndrome: Thoracic outlet syndrome involves nerves and vascular structures coming out of or passing through the upper edge of the chest cavity and is caused by compression. It is associated with bone or muscle abnormalities, and symptoms tend to appear between the ages of 20 and 40. It can be associated with occupational activities, poor posture, or neck trauma, etc. Most patients present with upper extremity pain, especially on the ulnar side, which can also radiate to the neck, shoulder, scapular area, or axilla, and very rarely the pain is located in the chest wall. An electrocardiogram and cardiac enzymology should be checked along with careful examination of the chest pain.
(2) Gastrointestinal disorders with epigastric and chest discomfort
(1) Reflux esophagitis and esophageal hiatal hernia: Reflux esophagitis is an inflammation of the esophageal mucosa caused by reflux of gastric contents into the esophagus, which can be complicated by esophageal peptic ulcer or stricture. The most common symptoms are retrosternal chest pain, burning pain, pain in the throat and “indigestion”, associated with eating or changes in position, and may include acid reflux, reflux of bitter liquids or gastric contents.
Esophageal perforation or rupture: The mortality rate is very high, mostly related to instrumentation or trauma, and other causes such as necrosis by compression of esophageal cancer. Automatic rupture of the esophagus mostly occurs as a result of dry vomiting or vomiting after a full meal, when pain under the sword appears and radiates to the scapular region. Patients may present with dyspnea, sweating and cyanosis, followed by pallor, tachycardia, shock and mediastinal emphysema. A chest x-ray may reveal a mediastinal emphysema and pleural effusion, and a barium swallow may identify the site of rupture.
Esophageal spasm and esophageal cardia achalasia: Pain and dysphagia are the main manifestations, nitrates are effective, swallowing is often the trigger of chest pain, especially into cold food, can radiate to the back, neck and jaw, each time lasts for several minutes or hours, activity does not increase the pain, but can be related to emotions. Physical examination is mostly abnormal, and barium swallow X-ray and manometer examination help to make the diagnosis.
④Acute abdomen: such as peptic ulcer or perforation, pancreatitis, cholangitis, cholecystitis and cholelithiasis. The epigastric pain present in acute abdomen can be confused with the pain or discomfort radiating to the upper abdomen from acute myocardial infarction, which can be severe enough to cause shock. Abdominal pressure and rebound pain, abdominal ultrasound and chest and abdominal X-ray can help in diagnosis, along with electrocardiogram and series of myocardial enzymology tests.